Researchers Try to Raise Quality of Extended Life : Health: The goal has shifted from lengthening the human life span to making those final years comfortable.
One of the crowning achievements of medical care in the last half-century is that people can expect to live a decade longer than their grandparents.
But as more individuals live longer, a new concern has emerged: Are these bonus years a blessing or a curse?
According to a growing number of clinicians and policy-makers, the aging of America will stagger the health-care system unless the final years of life can be cleared of chronic disease, disability and dependency.
So far, experts find little evidence that the extra years of life earned are healthful--or even comfortable.
That grim assessment has triggered a subtle but significant shift from research on increasing human life span to reducing the years of sickness at the end of life.
Or, quipped San Diego epidemiologist Elizabeth Barrett-Connor: “Can we die in perfect health?”
The tantalizing possibility of postponing illness and disability until just before death attracted leading gerontology experts to the Asilomar Conference Center in Pacific Grove recently for a conference sponsored by the National Institute on Aging. Participants included nationally prominent researchers in economics, medicine, sociology, demography and health services administration.
“Our concern is that we try to understand what is happening to life with increased life expectancy,” said Dorothy Rice, former director of the National Center for Health Statistics, now with the Institute for Health and Aging at Cal State San Francisco. “Is it a disease-free life? Are we compressing illness and disability at the end of life or are we extending (them)?”
Average life expectancy in the United States jumped from 62.9 years in 1940 to 74.9 years in 1987. Many experts predict an increase to 78 years by the year 2000 and an eventual limit, set by nature, of about 85 years of age.
Compounding the increase in life span, the U.S. population soon will be top-heavy with senior citizens as the baby boomers age. The number of people age 65 and older is expected to increase for the next 40 years.
The increase in life span is largely due to progress in treating heart disease and controlling infections and parasitic diseases. But the cost of longevity appears to be a surge in the number of disabled and chronically ill elderly.
For those who escape the grasp of the major killers, old age is often beset with chronic, non-fatal conditions, such as arthritis and high blood pressure, that diminish the quality of life and burden the health-care system, said Lois Verbrugge, a research scientist at the University of Michigan’s Institute of Gerontology.
“There’s a big problem ahead in the number of seniors coming,” said Dr. James Fries, the Stanford University immunologist who, in the early 1980s, first suggested the possibility of reducing sick years at the end of life.
Fries calls the concept “compression of morbidity.” Morbidity is commonly used as an umbrella term encompassing frailty, disability and the onset of diseases.
“It’s obvious that the cost of keeping people alive is an increase in disability,” said George Kaplan, chief of the Human Population Lab at UC Berkeley.
Strategies for maximizing the years of healthy life vary widely, however, and straddle the fields of economics, sociology and medicine.
But, said conference co-organizer Mary Haan, an epidemiologist with Kaiser Permanente’s Division of Research, experts are now united in their determination to square off against this Goliath of health-care issues. As evidence, among the major goals suggested by the National Institutes of Health is the attempt to inflate the years of healthy life from an average of 60 in 1987 to 65 by 2000. The goal is part of the NIH’s Year 2000 National Health Objectives.
In general, Fries said, experts are optimistic that--as they have warded off disease at younger ages--they can identify tactics to prolong life and, simultaneously, reduce chronic pain and disability.
Included in their strategy:
* Continued efforts in disease prevention in early years through exercise, nutritious diet and avoidance of smoking; prevention of chronic, non-fatal conditions such as arthritis, hearing impairment and vision problems; greater prevention of the major killers, such as cancer and heart disease, among the poor and minorities.
* Changes in medical care to emphasize rehabilitation, including physical therapy for people who are injured or recovering from surgery; improved training in geriatrics for doctors; limited use of life-sustaining medical intervention that does not add to the quality of life.
* Social influences, such as encouraging the elderly to remain living at home and in proximity to friends and relatives; improved access to recreation, shopping, religious resources and transportation; preparation for the effects of retirement.
Sex, race, culture, income and work status have much to do with the happiness and health of the final years, experts said. One study showed that women with children are more likely to enter a nursing home--where health often declines--in order to avoid burdening their sons and daughters. This attitude is generally not found among men.
The loss of a spouse is well known to increase the likelihood of death in the surviving spouse. And being unmarried is a risk factor for men.
In general, an individual’s ability to remain self-sufficient, mobile and in control of life score heavily on the side of good health.
But statistics so far have not shown an increase in years of healthy life. A study conducted by Kaplan showed that a 1974 group of Alameda County seniors citizens had more health problems and functional limitations than a 1965 group.
“Older people in Alameda County appear to be living longer but enjoying it less,” Kaplan said.
At the same time, however, interest in the compression of morbidity has also soared because Americans are demanding a higher quality of life as they age.
“Modern people expect to be healthy until the day they die,” said Sheila Johansson of Stanford’s Center for Humanities. “We are much more likely to seek help from an expert much further away from being dead. This is good. But this costs money.”
Finally, health-care providers are interested in planning for the burgeoning number of elderly and the services they will require.
Kaiser Permanente has obtained a four-year, $2-million grant from the National Institute on Aging to study 6,000 Northern Californians, age 65 and older, enrolled in the health maintenance organization. Researchers will chart 25 chronic conditions most likely to afflict the aged.
“I think Kaiser is interested from a practical standpoint,” Haan said. “The population is aging and, in the near future, this will have economic impact. We need to know how the utilization of services will change.”
Contributing to the economic crunch in health care, for instance, is the expected increase in the number of people with Alzheimer’s disease from 2 million now to 11 million by 2040, Rice said. Currently, elderly people absorb about 36% of the national health expenditures. That figure could bulge to 56% in 50 years. Nursing home beds could outnumber hospital beds tenfold by 2040.
While the Kaiser study has been heralded as an important icebreaker, experts agree that many more studies are needed to determine factors that increase years of healthy life.
Epidemiologists, for example, have assigned themselves the murky task of defining when and how diseases lead to disability.
In studies, Verbrugge found that the oldest of the old are saddled with arthritis, high blood pressure, hearing impairments, senility, poor vision and foot problems that cause pain, frailty and a feeling of vulnerability.
“These are essentially mysteries and black boxes. There is much less known about these conditions,” Verbrugge said. “There has been a short-shrift (given to) arthritis and other non-fatal conditions. Recognition of their existence is important.”
People with chronic, non-fatal conditions often drift imperceptibly into the group of dependent elderly requiring intensive care by family members or nursing-home staff, she said.
Overlooked in the march toward increasing life expectancy is the view of many elderly people that life is not worth living if it’s painful and causes problems for their families, said Dr. Christine Cassel, chief of general internal medicine at the University of Chicago Medical Center. Cassel opposes medical interventions that prolong life without adding significantly to quality of life.
“In an aging society, death is not necessarily the worst outcome,” she said. “We need to be much more quality-of-life oriented. We need to spend more money on non-fatal chronic conditions. We know precious little about prevention (of these diseases). This is a frontier area.”
Social and economic factors figured heavily in stretching life expectancy from 1940 to 1990, however, and some of the greatest gains in healthy years could result from improved economic conditions for the poor and minorities.
The relationship between health and economic status is distinct. Statistics reveal that the poor and minorities have achieved neither the life expectancy nor the same number of years of healthy life as have white, middle-class Americans. Life expectancy for whites is 5.8 years greater than blacks. But the disparity is considered so difficult to resolve that the NIH’s modest Year 2000 goal is to narrow the gap to four years over the next decade.
Researchers need to better understand how economic and educational status influences health. For instance, Fries said, one new study shows that the onset of arthritis occurs later among the well-educated upper class, although it’s not clear why. And a Finnish study showed that a low-economic status in childhood was linked to development of heart disease later in life.
Those researchers dedicated to compression of morbidity complain about the lack of funding for their cause. But, should more dollars become available, no doubt a vehement argument would follow about which avenue of research to pursue--and whether to begin at the beginning or the end.
One approach is to focus on early life to prevent the diseases and ailments that corrode old age. Others favor working backward, finding solutions to ease the inevitable.
